A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.)
Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
Please state the Responsiveness and Innovation of your practice
Statement of the problem/public health issue. The Aurora Syringe Access Services (ASAS) utilized an innovative approach to address Metro Denver’s need for comprehensive syringe services program (SSP) for people who inject drugs (PWID) through community partnership. In addition to the mortality and morbidity from opioid overdose[1], PWID are at higher risk of acquiring HIV and Hepatitis C (HCV) infection through sharing injection equipment and high-risk sexual behaviors. In 2016, 46.3% of Colorado’s acute HCV cases were attributed to injection drug use (IDU). The TCHD area represented 13.4% of Colorado’s acute HCV cases in 2016. The TCHD area had 128 new HIV cases (8.6 per 100,000)[2] and 17 cases (13.3%) were associated with IDU in 2017.
What target population is affected by problem? (please include relevant demographics) What is the target population size? Comprehensive SSPs reduce the risk of HIV and HCV infection transmission and prevent opioid overdose deaths. Between 2012-2015, the Harm Reduction Action Center (HRAC, a large downtown Denver SSP) had experienced a high volume of TCHD residents (921 participants) accessing their services. Of these, 31% of them were traveling from Aurora, experiencing transportation barriers. Although the actual HIV and HCV prevalence among PWID living in TCHD jurisdiction is unknown, according to the HRAC’s intake questionnaire, TCHD participants disclosed current HIV infection (2%) and HCV infection (18%). They also reported reusing syringes (87%) and borrowing syringes (35%) in the last 30 days at the time of SSP enrolment. Using a national estimate,[3] the ASAS’s target population is about 3,000 PWID currently live in the TCHD area (0.3% of 1 million adults living in Adams, Arapahoe, and Douglas Counties).
What percentage did you reach? What has been done in the past to address the problem? Between 10/5/16 and 9/30/18, ASAS served 328 participants; provided 1,174 interactions; enrolled 148 new participants; distributed 78,590 sterile syringes; and collected 67,956 used syringes. ASAS distributed 364 Naloxone kits (opioid antagonist). 15.3% of Naloxone-trained participants reported the recent use of Naloxone to save someone’s lives. Therefore, ASAS has reached about 11% of its target population in two years. Prior to the ASAS implementation, four SSPs existed in the Metro Denver area including HRAC (downtown), Boulder County (north), Jefferson County (west), Colorado Health Network (downtown). Transportation was a challenge for PWID population who live far from fixed SSP sites. In 2017, Colorado Health Network SSP moved to the east side of downtown.
Why is the current/proposed practice better? Is current practice innovative? How so/explain? Is it new to the field of public health? Is it a creative use of existing tool or practice? ASAS delivers innovative and comprehensive health services and syringe access services to PWID. ASAS uses a new, flexible, and systematic approach to address the public health problems (HIV and Hepatitis C infection morbidity and mortality, overdose deaths) in the communities.
The first innovative approach ASAS uses is the strong collaboration with community-based organizations (CBO). ASAS currently partners with three CBOs (HRAC [http://harmreductionactioncenter.org/], It Takes a Village [ITAV], Aurora Mental Health Center’s Homeless Services Program [AuMHC, https://www.aumhc.org/programs-services/specialized-services/homeless-services/]) to navigate neighbor relations and offer services where PWID already access other services. Initially, HRAC provided an outreach worker to help with the implementation of the ASAS program. HRAC continues to provide technical assistance, data management, ordering of supplies, and Naloxone standing order and logistics. Besides the day-to-day operational collaboration, HRAC utilize their credibility and trust in the PWID community in spreading the word about the ASAS during their SSP services and via their social media and informing the ASAS staff and participants about the current harm reduction best practices and policy advocacy initiatives in Colorado. ITAV provides services to African American communities, transgender communities, and people with history of incarceration. AuMHC provides homeless outreach and long term case management services for the homeless population. Both CBOs support ASAS with behavioral health navigation services.
The second innovative approach is a combined fixed site and outreach model. The fixed site is more efficient for large exchanges, convenient for housed participants, and offers HIV, HCV, and STI testing services. Additionally, the street outreach is more effective in finding new participants who have never accessed SSP at HRAC or elsewhere and addressing the transportation barriers among the homeless population.
The third innovative approach is harm reduction outreach activities outside of the Aurora area. ASAS staff provide the same quality harm reduction services (risk reduction education, wound care education, referrals, and the distribution of risk reduction materials) but does not include syringe exchange. Harm reduction outreach activities have been successful in building trust with PWID, reducing stigma about IDU in the communities, as well as providing active community resources referrals.
The fourth innovative approach is the provision of Naloxone training and the distribution of Naloxone kits. ASAS’s Naloxone program is comprehensive, including the distribution of Naloxone kits at the fixed site, during the street outreach, during the harm reduction outreach, through community Naloxone training (at the homeless shelters and the drug problem solving court), as well as the train-the-trainer training opportunities at CBOs and local law enforcement. ASAS assisted in training the Aurora Police Department dispatch officers to administer Narcan.
The fifth innovative approach is the implementation of fentanyl testing training, partnering with HRAC. Fentanyl testing strips detect the presence of Fentanyl in the substance therefore mitigating the adverse consequences from unintended use of fentanyl. During the syringe access service visits, participants are trained to use fentanyl strips and they are encouraged to report back the results at the subsequent visits.
Is the current practice evidence-based? If yes, provide references. Comprehensive syringe service programs (SSP) are effective in reducing harms (HIV and HCV infection, opioid overdose deaths[4]). It also promotes the resource and treatment services utilization. SSPs do not increase drug use or crime (https://www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf).
[1] Tri-County Health Department Opioids: Prescription Drug & Heroin Crisis Data and Resource Web Maps
https://tchdgis.maps.arcgis.com/apps/MapSeries/index.html?appid=0fa0cfda70ca4848b4238be48c6396e1
[2] Colorado Public Health and Environment data
[3] Lansky A, Finlayson T, Johnson C, Holtzman D, Wejnert C, Mitsch A, et al. Estimating the
number of persons who inject drugs in the United States by meta-analysis to calculate national
rates of HIV and hepatitis C virus infections. PLoS One. 2014;9(5).
[4] https://www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf